The Doctor Will Not See You Now.

AuthorGoozner, Merrill

Primary care is a disaster. Consolidation is making it worse. And a revolution is coming.

Tried to find a new primary care physician lately? Insurers must provide you with a list of doctors, but you quickly discover that few are taking new patients. When you do find one, your first appointment is scheduled for two months out.

When the day finally arrives, the doctor seems nice, knowledgeable, but more than a bit frazzled. She spends most of the 13-minute visit entering data into a computer as you answer the same questions that were on the paper forms you filled out in the waiting room. You assure her you've been vaccinated for COVID-19 at a local pharmacy, but she has no record of it. You walk out without a referral for a long-overdue colonoscopy.

Dr. Sarah Mullins once ran a practice with similar flaws in Wilmington, Delaware. "Care was disjointed, unorganized, and there was a lack of communication," she told me. But today, her practice, which employs four primary care physicians and five nurse practitioners for more than 10,000 patients, has been radically transformed.

Its doctors spend a half hour with every patient. The nurse practitioners leave part of their days unscheduled so the practice can offer same-day appointments to patients with pressing needs. They also act as care managers--reaching out to schedule wellness visits, vaccinations, and other preventive services. Patients' electronic medical records incorporate data from hospitals, specialist referrals, urgent care clinics, and pharmacies, enabled by a comprehensive state health information network that didn't exist a decade ago--and still doesn't exist in many parts of the country.

"I spend less time searching for vital data," Mullins said. "My staff is reaching out to schedule wellness visits while I have dedicated time to preventing illness and suffering. It's a shift that's changed our practice into one that helps people more and in a more organized fashion."

It's also far from the norm. In most of the U.S., primary care is in deep crisis. Family physicians are reporting high levels of stress and burnout, thanks to a reimbursement treadmill that requires many of them to see four patients every hour in order to make a living. Older physicians are retiring prematurely. Heavily indebted medical students are shying away from family medicine and pediatrics, which pay less than half the $500,000-plus salaries offered to surgeons, cardiologists, and other specialists. When surveyed, few newly minted doctors express interest in joining community-based practices, preferring the set salaries that come through employment with large institutions.

The deteriorating state of primary care is undermining every effort to rein in America's bloated health care budget. Family physicians, who are both the most trusted and lowest-paid doctors in the United States, provide routine and preventive care to patients with common but complex chronic conditions, like high blood pressure, diabetes, substance abuse, and mental health disorders. As primary care has gotten worse, many patients with these illnesses have found themselves growing sicker and in need of expensive medical interventions. This has driven up health care spending while driving down outcomes. Between 2014 and 2019, the share of U.S. GDP spent on health care rose even as life expectancies fell. (Life expectancies have fallen further since 2019, but later data is skewed by COVID-19.)

But as the transformation of Mullins's Delaware practice shows, it doesn't have to be this way. New models for reinvigorating primary care are emerging from both the public and private sectors. They have the potential to dramatically lower costs while improving the overall health of the American people. Yet expanding these isolated experiments into system-wide change will take major reforms of the federal policies that govern how we pay for care, and who we put in charge of our health.

Since the early 1970s, U.S. spending on health care has increased faster than both inflation and wages. We now devote nearly 18 percent of the economy to health--40 percent more than any other country--yet our population trails peer nations on every measure of public health, from longevity to infant mortality to incidence of chronic disease. The expensiveness and poor outcomes are causally connected. Growing health care costs have depressed wages, as employers redirect would-be raises into insurance plans. They have forced individuals to fork over growing shares of what income remains to insurers and providers. This has left a greater share of the population suffering from inadequate housing, food insecurity, and substance abuse, which in turn increases demand for the most costly health care services.

The only way to break this downward spiral is to invest more in primary care-led prevention and social services, which have declined from 7 percent to just 5 percent of total health care spending over the past several decades. But the obstacles to doing...

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