The hardest-working primary care doctors face one reality: Their best treatment tool is time.

Time to take a patient history which leads to the diagnosis. Time to counsel a patient who is struggling with an illness. Time to coordinate a patient’s care so that the odds of the right outcome are improved significantly.

The hardest-working primary care doctors face one enemy: Their best tool, time, is that which can not be produced in larger quantities. They all get the same amount of time to do ever more work. The more complicated medicine becomes, the more a good primary care doctor must do to help the patient make his way through testing to diagnosis and treatment.

They lose time dealing with a steadily-growing administrative load, which has become a second job for many practices, especially smaller ones.

Back in the early 1990s, managed care companies dangled a carrot in front of primary care doctors: They would be the “gatekeepers” for their patients, assuring that the use of more expensive specialists was “appropriate” and getting a handle on costs generated by higher-priced specialty care which was unnecessary. In return, primary care physicians would get two fees. The first fee was for managing care more effectively to their patients. That fee was called “capitation” because primary care physicians would be paid for each of their patients.  The second fee was based on a formula by which these practices would be paid bonuses if their practices provided care which, overall, care cost less.  Doctors who managed care most cost-effectively would get bonuses.

Capitation, 90s-style, bombed.

It put the primary care physician in the middle between the patient and the specialist in ways that did not serve the relationship well.

Their offices were flooded with requests for referrals.

(1) Doctors had to stop and explain to patients why the referral requests were not appropriate. Say “no.”

(2) Doctors had to stop and refer patients to specialists when appropriate. These referrals became a messy and more time-consuming process.

-  The primary care doctor may have had to re-refer a patient to a specialist chosen before capitation.  For example, a long-time heart patient had to ask for an okay to see the cardiologist to whom the doctor already had sent the patient last year or the year before.

- Doctors had to stop and find a specialist who was was “in-plan,” not an easy task, as the plans cobbled together their networks. This also meant long-standing referral relationships were disrupted. The cardiologist, for instance, the doctor liked best may no longer have been “in-network.” A search for another specialist had to be done.

Not only did this eat time, it eroded trust. Patients who began to understand the “bonus” reimbursement concept wondered why their doctors were saying “no” to a specialty referral request. Was it because they would make more money by saying “no?” What was that “no” really all about?

This made patients furious. They complained loud and long to office staffs. Suddenly, these offices became zoo-like. Wild. Loud. Crowded.

Except for the long-established HMOs, such as Kaiser Permanente, capitation was an idea whose time had not come, however great it looked on paper.

In a New England Journal of Medicine online-only post in “Other Points of View,” an academic proposes capitation of a different kind. No gate-keeping. The method: Pay these physicians by the number of patients they care for to remedy the primary care shortage. That’s it. No back-door bonuses. Everything out in the open.

Now, there’s an idea.

This could really work. Capitation payments to primary care doctors would be something like what the “concierge” practices are all about except cheaper. You may have read about them. Patients pay their physicians an annual fee for caring for them, assuring them a “place” in the practice, prompt return telephone calls, etc.  In return, the doctor knows that overhead and salaries are covered for the year, how many patients he or she is responsible for and can manage accordingly.

Yes, the patient continues to pay for health insurance. These concierge practices are “out of network” and not inexpensive. Patients, then, get only reimbursed as much as  is allowed for an “out of network” physician visit. Other services, assuming they are in network, are covered as they have been.

By contrast, this writer’s idea would make this model in-network but not in the same way as it is today.

Physicians, who have to be highly competitive to get into medical school and complete training, are wary of any system which does not reward “competitiveness” and hustle. You want to make money? Earn it. No free rides.

What this writer below is proposing is not a free ride—a set annual salary—but enough financial stability to make primary care an appealing specialty again.

Without primary care doctors available, patients lose.

Without primary care doctors, health care services are delivered in more little pieces, unconnected to a whole.

This may or may not be the answer to the primary care crisis. It is not over-heating the discussion to call it a crisis. The front porch of medicine is falling in. More primary care physicians are retiring than there are young doctors in training to take their places.

Some ER physicians are reporting they are seeing insured patients, many of whom say they have primary care doctors, but who can’t get an appointments. They have “access” to a primary care doctor, according to the formal definition (they are a patient in a practice with a record), but in real life, they don’t.

Everyone from health plans to elected officials say primary care is important, but in the pull and tug of trying to get health care under control, without fail, primary care loses every time to larger, better organized interests, such as drug companies, health plans, medical manufacturers and hospitals, to name a few.

A solution must be found. This proposal is worth a good look.

New England Journal of Medicine

…”Primary care was supposed to be paramount under managed care. “We need you to be gate keepers,” we were told, “and we’ll pay you well to perform that service.” In actuality, remuneration for primary care decreased under managed care, as contracts were negotiated solely on the basis of cost. Continuity of care was disrupted, as managed care relegated primary care doctors to ambulatory settings, replaced them with nurse practitioners or physician assistants, and utilized hospitalists for inpatient care. Worse, patient panels were dissolved and reassembled annually during open enrollment, as companies negotiated not with doctors, but with employers.

“So how can we fix the problem? Why not simply mandate that all payers, public or private, pay a capitation fee or salary designed to assure that primary care doctors can achieve a professional standard of living? In exchange, primary care doctors would provide continuing, comprehensive primary care (including night call and preventive services) for a reasonably sized panel of patients. For the sake of discussion, I would suggest a salary and fringe benefit package of about $300,000 per year (in 2009 dollars) to care for 2000 patients, ($150 per patient), with incentives for special circumstances (e.g., working in underserved communities) or special services (e.g., delivering babies). All other fees, deductibles, and copayments would be waived. The problem of physician-generated demand would be eliminated, which would radically reduce costs to insurers. Billing would disappear. Patients would have open access to their primary care physicians. Freed from the constraints of billing for the traditional encounter, primary care doctors could employ innovative methods to deliver primary care, including the Internet and group encounters.”

Arthur M. Fournier, M.D.
University of Miami Leonard Miller School of Medicine
Miami, FL

Citation: New England Journal of Medicine, Posted August 19, 2009: Health Care Reform 2009