When I started our Crossover Health journey ten years ago, one of the forces driving me was the decline of great primary care. It may initially seem a bit odd for an emergency medicine physician to feel this way, but it was really driven by self preservation. In emergency medicine, we are acutely aware of the fragile safety net —as the provider of last resort, we are literally on the front lines as the default primary care for the masses. My experience was that 70% of what I saw in the Emergency Department did not actually need to be seen in this uniquely designed high-acuity, but extremely high-cost setting. Simple things that could be handled with time and over time were instead magnified and multiplied in this “one shot” setting (grandpa hitting his head resulted in a CT scan because I had neither time to be wrong nor the opportunity to reassess). I often wondered where all my primary care brothers and sisters were, and why their care wasn’t accessible when it was most needed.
I subsequently came to learn it wasn’t so simple. There wasn’t a business model that would allow for nor incent primary care physicians to be available beyond the routine business hours of 8 – 5 PM. There were innumerable studies and surveys illustrating the dissatisfaction, the perceived lack of respect, the CPT codes skewed towards specialities and—inevitably—the burn-out that so many primary care physicians faced. And, naturally, this all affected their ability to adequately care for, let alone be available for, their patients. The unhappiness in primary care has been palpable over the last two decades, and even more pointed because at the same time there were plenty of papers and articles pointing out the critical, foundational role primary care played in achieving the Triple Aim. Primary Care has always been absolutely necessary but in its current form, woefully insufficient.
Fast forward ten years, and I’m reading a news article that Geisinger, a nationally-acclaimed integrated health system and insurance company based in Pennsylvania, is going to pay the tuition costs of students in its medical school who select primary care as a career (fineprint: as long as they commit to primary care practice within Geisinger after graduation). In and of itself, this is actually a very smart move that should be paid attention to, given its endorsement from one of the more innovative health systems in the country. It has been noted that medical students can end up with ~$250,000 in debt after their training, and given the issues cited above, many economically-rational medical students elect to go to higher-paying specialties. Geisinger is choosing to solve this dilemma by going to the root cause, starting all the way back in year one of medical school to address the PCP shortage.
But from another perspective, this speaks to the fact that after all these years, the fundamental issues surrounding primary care remain. It’s not just about the money (although, let’s be real, poor primary care salaries are certainly a key driver). The bottom line truth is that primary care is simply not as rewarding as it should be. It’s hard work, which is no problem on its own (medical students are typically incredibly hard-working and have an innate ability to delay gratification), but when combined with lack of autonomy, respect, and control (increasingly limited practice options, billing and administrative pressures, ever more complex admin, regulatory, and technical challenges) it is no wonder that primary care numbers continue to dwindle. It’s still “hamster wheel” medicine, where more than 90% of practices are measured on volume not value, transactions not relationships, and questionable upcoding rather than meaningful outcomes. Kevin Pho, MD, an internal medicine physician and author of the popular blog KevinMD, had a post earlier this year (written by an ER Physician!) describing the imperative to take physician satisfaction seriously. I feel like this could have been written in 2009 as easily as 2019, and while the voice is now more strident, the message is plaintively the same.
The reality is that no amount of tweaking the existing fee-for-service system will change the reality for primary care physicians. All of it—the payment model, the poorly integrated and frustrating tech, the focus on specialties—has to be jettisoned. Crossover’s Connected System of Health points the way to a rich future for patients, providers, and even payers – one in which the theoretical value of keeping people well and embracing their health is realized within a primary practice model that is both effective and rewarding. Maybe ten years from now we won’t be reading articles like these . . . but I won’t hold my breath on the old system changing. And, that’s why we won’t stop trying to breathe new life into newer care models and a better health system.