How Can Primary Care Be Improved in the U.S.?

WASHINGTON -- Are you taking Fridays off at your medical practice? If so, you're not alone, said Ishani Ganguli, MD, a primary care physician at Harvard Medical School in Boston, at a primary care forum here Thursday.

"We see this 20% dip [in office visits on Fridays] -- specialist visits more than primary care visits," Ganguli said at the event sponsored by Primary Care for America. There is also a drop in people coming in to have procedures, lab work, or imaging tests on Fridays.

"It's fascinating because [it shows] that we've designed care around the clinicians," she added. "I would bet that patients prefer to have some procedures on Fridays so they could recover over the weekend, but we're not seeing that. So measuring this may be one step towards centering ourselves more around our patients."

One problem for physicians who want to add weekend and evening hours to their practices is that "the majority of physicians are employed now" rather than running their own practices, said Darilyn Moyer, MD, executive vice president and CEO of the American College of Physicians. "And even though they know that's the right thing to do, they do not have the power at the organization. So I think the message is that the payers and the credentialers and licensers of these organizations need to have more specific rules around funding these important initiatives."

Kameron Matthews, MD, JD, chief health officer of Cityblock Health here, said that one of her best experiences with a health provider "was with a dental practice in Chicago that had 7 days a week, 12 hours a day of of scheduled appointments, even on Saturdays and Sundays."

"The fact that we are still fighting a lot of practices to have evening hours, even to 7 p.m. or Saturday hours" is unfortunate, she said. "For the 18-to-64-year-olds, for the working population and definitely for the underserved population that do not have the ability to take leave, and often have also transportation difficulties -- the appointment alone is not just the inconvenience, it's also the arrival and departure time and the childcare and the like. We need to think about how we say that we're patient-centered, but we're clearly not."

The current state of primary care is "fragile and weakening," said Chris Koller, president of the Milbank Memorial Fund in New York City. He highlighted conclusions from the fund's report on the health of U.S. primary care, which came out in February:

Payment and investment. "We spend less money on primary care as a portion of our total expenses than any other country," said Koller. "Over the last 10 years, that investment has stayed flat or gone down across all payers -- Medicaid, Medicare, and commercial."

Access. Koller noted that patients who have a "usual source of care" -- regardless of what it is -- have fewer visits to the emergency room, improved health, and better chronic care management. However, "in the U.S. in the last 10 years, the number of people not reporting a usual source of care has gone up from 22% to 29%," he said. The increase is happening across all types of payers, "so it's not just a high deductible issue ... And this is [happening in] a period when insurance access is increasing."

Another part of access is physician and clinician supply, "and we've found there's enormous variation across the country around the number of primary care clinicians and NPs [nurse practitioners] and PAs [physician associates] per capita, and that variation is increasing over time," Koller said. "The regions and communities that are medically underserved areas -- Health Professional Shortage Areas -- those are experiencing greater gaps compared to the rest of the rest of the country."

Workforce training. "The numbers here are really simple," he said. "In 2010, 1 out of 3 doctors were in primary care, but in 2020, our schools are producing 1 out of every 5, so we're not replacing clinicians who are retiring. And we are training our primary care clinicians on the coasts and in hospital settings, rather than in communities in teams. So frankly, our medical education system is failing in terms of giving us the clinicians that we want."

Research. Although people may think that spending only 6% of U.S. healthcare dollars on primary care is low, "keep in mind that the portion of research money that goes to primary care is 0.2%," said Koller. "So 6% is bad enough, but in terms of where our priorities are -- where we want to learn, where we want to grow -- we're putting nothing in primary care."

Even when medical students receive training in primary care, it may not be the best quality, added Matthews. "Anecdotally, the medical students that I work with regularly -- through both nonprofit as well as past academic experiences -- are also really speaking about the lack of quality to the primary care training that they are receiving."

That includes "extremely negative experiences with the faculty, usually adjunct if it is even community-based, the very negative experiences that they are having with these connections where they automatically step away from their primary care rotations in medical school and say, "There's no way; I would never want that," she said. "So the screening by medical schools of what adjunct faculty they're using, the accountability there, I think needs to be addressed."

Although primary care physicians can't be expected to fix everything wrong with the U.S. healthcare system, "I'd like to see a payment model that would allow them to fix more problems than they currently can," said Fritz Busch, principal and consulting actuary with the Milliman consulting firm, which sponsored the forum.

For example, although the average office visit is 7 minutes long, "I don't know of any competent professional who can execute their core competency in 7 minutes ... The key element is time."

Correction: This story was updated to clarify that the event sponsor was Primary Care for America, not the American Academy of Family Physicians.

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