In order for the patient population to benefit best from any medical system and especially a universal healthcare system, the care team ministering to the patient must be, ideally, headed by a PCP (primary care physician). Specifically, I believe that every patient in the United States should have a physician who is in charge of that patient’s care. In direct care, the PCP should handle vaccinations, preventative screenings, interval wellness checks, acute care visits, and chronic care visits (e.g. hypertension, diabetes, hypercholesterolemia, asthma, etc.) Direct care is usually office-based. The PCP should also be responsible for indirect care of the patient, including referral of the patient to vetted consultants and coordination of care when the patient is hospitalized. The 3 types of primary physicians are family practitioners, internists (adult medical care) and pediatricians. Pediatricians care for the young patients (newborn to 18-21). Internists care for patients typically >=18. Family practitioners care for patients of any age. These days, there are physicians who undergo a more extensive residency training and are board eligible in both pediatrics and internal medicine. Each group of PCPs have different and unique training.
A PCP should be fully in charge of the entirety of a patient’s care. If at all possible, a PCP should see his/her patient at least once a year or more as dictated by circumstances. In practices where the patient population is younger and healthier, the PCP may have mid-level surrogates such as nurse practitioners (NP’s) and physician assistants (PA’s) perform a greater amount of patient care including well patient yearly visits and acute care visits. However, as the patient population skews older, suffers from chronic illnesses, or presents with a new high severity complaint (chest pain, shortness of breath, abnormal heart sensations, etc.), a primary care physician is a better match to the patient’s needs.
Since the PCP is the “conductor” of the medical orchestra, other physicians should coordinate care through the PCP, i.e. the system should follow a chain of command, acknowledging the primacy of the primary. A PCP is usually well-versed in a universe of consulting physicians. Non-PCP clinicians should avoid the urge to refer patients to additional consultants without coordinating with the primary. As hospital systems become more aggressive, there seems to be more hospital-controlled ER physician referrals to other hospital physicians (what I would term “consanguineous” referrals). Coordination of care for these patients becomes more difficult and chaotic with these referrals. As a PCP, I had a large vetted population of consultants whom I trusted for great patient care and coordination. In addition to ER physicians referring without the PCP’s coordination, a surprising number of consultants refers patients to other consultants in a different field, again without PCP coordination. Uncomplicated patients with elevated glucose values are sometimes forwarded needlessly to endocrinologists. Dehydrated patients whose renal parameters drift upwards are sometimes forwarded also needlessly to nephrologists. Hypertensive patients are needlessly referred to cardiologists. Poor coordination leads to undue patient suffering and costly, inefficient care.
If a primary is doing his/her job, there is far less chaos in patient care. This in turn leads to significant cost savings. In “Primary Care: Why It’s Important and How to Increase Access to It” by author Web Golinkin (who frequently comments on healthcare) from February 23, 2024 in Forbes.com, 3 assertions were made (borrowed from the Purchaser Business Group on Health 2021):
- U.S. adults who regularly see a primary care physician have 33% lower health care costs and 19% lower odds of dying prematurely than those who see only a specialist.
- The U.S. could save $67 billion each year if everyone used a primary care provider as their principal source of care.
- Every $1 increase in primary care spending produces $13 in savings.
With respect to the 1st assertion, there is a 33% reduction in costs by seeing a PCP rather than a specialist alone. I will extrapolate that there is >50% reduction in costs compared to those who use the ER solely for the care, i.e. those who don’t use a PCP at all.
With respect to the 2nd assertion, as a PCP myself, I suspect that is $67,000,000,000/year savings is wildly conservative. It is more on the order of hundreds of billions of dollars per year.
With respect to the last assertion, well, it speaks for itself.
We all need PCPs and everyone in the United States should have 1. That person is bound by a sacred social contract to give, directly or indirectly, every patient in the practice the best possible care. In review, this includes monitoring and arranging preventive care (vaccinations, interval examinations, blood screenings as necessary, mental health screenings, etc.) The PCP should also offer timely appointments for acute care events, e.g. sore throats, flu, injuries, mental health concerns, and many, many additional complaints. Care under the guidance of referral consultants, ER physicians, and inpatient physicians should all coordinate through the primary. In terms of total responsibility of the patient, the buck stops at the PCP. A patient should never fear becoming “lost” in the medical system if he/she has a PCP.
So what is preventing us from achieving this goal that every patient in the United States have a PCP? The answer, as usual, is money. Medical students, residents, and fellows carry an enormous financial burden when completing medical training. Primary care is not procedure oriented. Many other fields are almost entirely procedure oriented. Proceduralists (surgeons, cardiologists, gastroenterologists, interventional radiologists, etc.) can pay training debt more rapidly than primary care physicians can. In my own circumstance, it took me approximately 20 years to pay off all my medical school loans. My ophthalmologic colleagues who did 10 lens replacements in a day made more money that day than I would in a week (or more!). Medical students are fairly smart and if society awards more money per hour for doing procedures than for preventing and intervening early in disease, who is to blame them for not fighting an uphill battle.
Let us take a step back and think about this further.
By creating a system that skews better reimbursements toward physicians treating the sickest patients needing procedures, the system reinforces itself. This harkens back to the discussion about Markovian cascade where we failed to prevent or intervene early but rather spend the dollars when the patient is sickest and therefore most expensive. However, going back to the 3rd assertion above, for every additional $1 paid for primary care, we save $13. To solve the dilemma of losing all the PCPs and overpopulating the system with highly reimbursed proceduralists, one must shift some of those dollars back to the primary care physicians. To save money, one cannot replace these physicians with mid-level clinicians such as nurse practitioners and physician assistants (could you imagine the reaction if insurance companies insisted that gallbladder surgery now be done only by nurse practitioners and physician assistants to save money?) Mid-level clinicians are highly valued parts of the care system but are not trained as physicians.
Again, in order for this to work, the primary care physician must lead the care team. ER physicians should consult with the patient’s PCP for complicated situations, e.g. admissions to the hospital or timely follow-up care if the patient is discharged directly from the ER. Hospitalists who take care of a PCP’s patient must coordinate with the PCP regarding the patient’s continuity of care after discharge and even, ideally, if the patient has a major change of status while hospitalized. All the consanguineous referrals within a hospital must be stopped.
The above, I assert, is a recipe for much higher quality of care at a lower cost. We must evolve into this. This is a win-win.